Record Keeping

Record KeepingAccurate and prompt documentation minimises disagreement about the facts, and results in an audit trail that can help relate future problems to past patterns of performance or behaviour.

Good records also reduce the scope for future challenge. All trainees have the right of appeal, and documentation will be required by appeals panels.All documentation must comply with the requirements of the Data Protection and Freedom of Information Acts in relation to processing, retention and security of records.

Records relating to a TiD may subsequently form part of regulatory proceedings. Therefore recording of information must be of a standard and character where undue legal challenges can be avoided. Records of conversations should be held confidentially with the knowledge and consent of both the trainee in difficulty and the person who has conducted the assessment of the problem.

The trainee should be given a copy of any documentation concerning his or her performance and encouraged to keep such copies in his or her records or portfolio for discussion at appraisals. She or he should be made aware of where the notes will be stored and who will have access to them. The Freedom of Information Act (2005) allows the right of access to information held about practitioners/trainees (subject to exemptions where appropriate) and so any documentation could be accessed through this.

The content of any notes of meetings or of agreements reached should be agreed with the trainee wherever possible. The chair of the LFG or DME may choose to anonymise the individual trainee in the minute and s/he will be responsible for keeping the key to the coding confidential.

General Principles

  • Record the place of the meeting/time/length/names of those present
  • Record notes promptly after any meetings/event and agree it with those present as soon as possible (within two weeks)
  • Information about a trainee presented to the LFG should ideally be recorded in a ‘standard concern form’ within the relevant school’s operational guidance and completed by the educational supervisor and the chair of the LFG
  • The LFG may discuss the matter in detail but the minutes should only contain a factual summary. (The individual supervisor concerned should hold detailed notes of training etc but this must not form part of the minutes).
  • The trainee has the right to see the information held.
  • Principles of equality and diversity must be observed.
  • Exclude information about aspects of the trainee’s life not directly related to his or her work even if discussed during the course of the meeting for other reasons.
  • Record discussions in a balanced way. The minutes should be objective and unbiased, written in an accurate and concise style. Once written, they should be checked for accuracy and distributed to the members as soon as possible.
  • At the end of formal meetings confidential information sheets should be returned to the responsible officer to be shredded in line with local trust policy
  • The minutes of trainee in difficulty meetings should be recorded in bullet points as follows:
    • issues raised
    • conclusions
    • action points and time lines
    • review date

Telephone Conversations

Telephone calls regarding a trainee’s performance or behaviour should also be documented and stored as outlined above. Consideration should additionally be given to sending the notes of the conversation as an email or letter to the caller as an opportunity to confirm their accuracy (see e mail guidance above).

There is also an NHS code of practice on record-keeping which applies to administrative as well as health records. These can be accessed through http://www.ncas.npsa.nhs.uk//

E-mails

  • Should not include the name of the trainee in the subject line, but eg ‘confidential’
  • Should be brief and factual
  • There should be a separate e mail for each trainee discussed
  • A copy should be stored or filed with other records
  • Where possible, the trainee should be copied in records of conversations should be held confidentially with the knowledge and consent of both the trainee in difficulty and the person who has conducted the assessment of the problem. The trainee should be given a copy of any documentation concerning his or her performance and encouraged to keep such copies in his or her records or portfolio for discussion at appraisals. S/he should be made aware of where the notes will be stored and who will have access to them. The content of any notes of meetings or of agreements reached should be agreed with the trainee wherever possible. The chair of the LFG or DME may choose to anonymise the individual trainee in the minute and s/he will be responsible for keeping the key to the coding confidential.

Storing and transferring information

Generally the relevant authority eg the specialty school should be kept informed. Information should be stored securely eg through password protection on computers or in locked filing. Minutes of notes need to be retained for seven years.

When a trainee moves to a new employer the transfer of information about any disciplinary or competence issue is important, both for patient safety and to support the trainee.

Information transferred should take the form of a written, factual statement about any formal actions taken against the trainee and the nature of any triggers, but not about incidents where the trainee was exonerated. The trainee should be informed of the transfer but patient safety must override personal confidentiality. If the doctor moves again, the problem escalates or others become involved, it may become necessary to pass the record to others, again with the consent of the doctor where possible. Transfer of information about trainees’ progress from post to post should become standard procedure including areas of concern. The sharing of information must be with permission of the LFG chair. Very sensitive information is best transferred by a dean, foundation or specialty school director to the new trust‘s DME.

 

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